SDS Accreditation Update: Surveyor in the ceiling, and one patient scheduled
Surveyor in the ceiling, and one patient scheduled
Be ready every day for your survey
When she read the news stories and alerts from Joint Commission on Accreditation of Healthcare Organizations about fake surveyors, Suzanne L. Broome, RN, center director of Blue Ridge Surgery Center in Seneca, SC, instructed her staff to be sure to check the identification of anyone who claimed to be a surveyor. A few days later, when only one case was scheduled and all staff members except Broome and one other nurse were off for the day, the receptionist called her to say that the Joint Commission surveyor was in the lobby.
"I play practical jokes on my staff, so I thought this was a joke on me," says Broome. The timing of her instructions to the staff about identification checks and the lack of staff at the center made her respond to the call with, "Don't pull my leg," she says.
It was a Joint Commission surveyor, and he spent the first of his two days at the center looking at policies and examining the physical facility because of the lack of patients to trace or staff members to interview, she says. There were no surprises with the questions the surveyor asked, but Broome was surprised by his detailed examination of the building. "He asked for a ladder, then climbed up to look into the ceiling and check the firewalls," she recalls. "He made sure that the firewall did go all the way up to the ceiling and that there were no unsealed holes in the wall."
The surveyor also looked carefully at a performance improvement project conducted by Broome's staff. "We studied antibiotic reactions that occurred in two patients to determine the cause of the reaction and prevent future reactions," she says. "We discovered that we infused the antibiotic too quickly, and we retrained our staff to make sure we prevented future reactions." While Broome thought the performance improvement study fulfilled requirements, the surveyor indicated that he would prefer to see a proactive as opposed to a reactive study.
"This year, we are surveying our physicians to determine satisfaction levels," says Broome. "We have undergone staffing changes and added new equipment, so we believe this will be a good proactive study to identify any potential dissatisfaction before we hear complaints."
The performance improvement study that resulted in standardized forms to collect patient and procedure information received high marks from the surveyor who visited Rogers Park One Day Surgery Center in Shelby, NC.
"Standardized forms eliminate the opportunity to miss information or signatures that are needed for consent forms and other surgery forms," says Evan Giline, RN, director of nursing for the center.
While the surveyor did trace a patient's progress through the center, there were no surprises related to clinical care, says Giline. However, they do need to redo their handwashing policy, she says. "Some of our staff members were not washing their hands between patients because they were changing gloves between patients," Giline says. The surveyor pointed out the need to wash hands between patients, even if new gloves are used for each patient, she adds. "We are re-educating staff members about all aspects of hand washing, including how to wash, when to wash, and how to scrub nails," she says.
Sources
For more information about survey experiences, contact:
- Suzanne L. Broome, RN, Director, Blue Ridge Surgery Center, 10630 Clemson Blvd., Suite 200, Seneca, SC 29678. Telephone: (864) 482-5100. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.